Respiratory Therapy 101: Just Keep Breathing

One of my hobbies is to get people going. If you know exactly where the line is, you can walk along it for a few minutes without stepping over it. This gets people pretty worked up, but when they discover that you’re just kidding they usually see some humor in things. And the agitation is good for them: the increase in blood pressure, heart rate, and respirations is sort of like exercise. I view my hobby as a public health service: getting people going is good for them!

So the other day when I ran into my boss standing near our hospital’s infection control officer I had to see what I could do. I walked inconspicuously past, then stopped and smiled.

“Hey boss.”

“Hey, RT. How’s it going?”

“Just fine. My patients are eating so I figured I should too, (insert phony conversational laughter here.) Say, infection control, have you seen that guy in CCU with the crazy infection? What is that?”

The infection control officer frowned for a moment.

“That’s a weird case because we don’t really know what he has. It’s some unknown new pathogen. We’re hoping we can figure it out. It would be awful if that spread around.” I nodded knowingly and crossed my arms, putting on The Serious Face.

“Well I’m doing my part. I believe that exposure is the better part of immunity.” The boss became perceptibly nervous as I said this, shifting her weight between her feet and looking uncomfortable. The time was right to deliver the killing blow. I took a deep breath and carefully controlled my expression.

“That’s why I never ever wash my hands.”

There was an awkward pause. I stood straight and focused on not smiling. The Boss began to laugh nervously. The infection control officer seemed extremely startled and there was a glorious moment of complete awkwardness as the two of them stared at me in disbelief. Finally I couldn’t control myself any more and I burst into laughter. Once the two of them realized I was just kidding they began to chuckle nervously, and I reassured them that I was merely joking and made my escape before retribution could begin.

Another notch in the gun, so to speak. I’ll just have to steer clear of the boss and hope she doesn’t manage to get me back.

As promised, something funny to compensate for the bitterness. From Basic Instructions, I give you one of my favorite images of all time (click to enlarge):

It’s perfect, isn’t it?

(Image stolen from Basic Instructions without a hint of a scrap of permission. Copyright belongs to the comedic genius Scott Meyer.)

Ah, Complementary and Alternative Medicine! Such a controversial topic, full of intrigue and shady evidence and passionate arguments from many different people. Speaking personally, I don’t have an issue with CAM; indeed, I know and am related to many people who swear by things like acupuncture and herbal remedies. When I was but a wee lad, my mother pumped me chock full of herbal remedies in a loving but possibly misguided* effort to avoid putting “chemicals” into my body.

The problem that I have with CAM is when people use it exclusively, claiming that real medicine is misguided or somehow deficient in ways that CAM is not. I have family members who, when they experience physiological malfunctions, will eschew a trained physician in favor of an herbalist.

Now, in some cases I can see their argument for deficiency in modern medicine. In theory, medicine is “evidence based” but in practice many physicians and practitioners are really “litigation based” or “I learned it that way 20 years ago based.” This does lead to deficiencies in care. However! The fact is that most medicine is based on some body of solid research, where most CAM is based on flowery prose with a minimum of solid research. I’d make the argument that CAM is marketed by people who have an economic incentive, but so is real medicine, so that argument is not a good one to use.

So given the fact that modern medicine is backed by evidence and CAM is not, why do so many people continue to prefer using CAM only? To find the answer, I have turned to that ancient illuminator of the truth: comedy!  The humorous and surprisingly accurate website Stuff White People Like gives us an excellent answer to the problem of CAM:

Because of a rather shady history, white people do not trust the pharmaceutical industry.  Using pretty sound logic, they believe that the drug companies have no motivation to find real cures for things like AIDS since the real profit are in drugs like Viagra and Xanax.

Using their powers of deduction, white people have determined that herbal remedies are unilaterally better than anything produced by a drug company.

Since white people can’t really blame any race for their problems, they need to blame corporations.  In this case, the reason that they are sick or fat or without energy is because the drug companies are in a conspiracy to keep them addicted to placebos.  This helps them shed accountability, and it lets them feel like they are helping the environment by rejecting the polluting, greedy, awful drug companies and taking natural, organic medicine from the earth.

But perhaps it goes deeper.  Hundreds of years ago, another group of people believed firmly in natural medicine and it’s ability to cure disease.  Then white people gave them blankets with small pox and they all died.  So perhaps turning to natural medicine also helps white people feel better about killing natives.

Once again, comedy helps us see the truth.

*Pretty much everything we do boils down to chemicals in action. Trying to avoid putting “chemicals” into your body is like trying to avoid putting “air” into your lungs.

There are two things that have really gotten out of hand lately. One is those little bracelets that come in a variety of colors that are supposed to show how much you support a cause. You know the kind I mean, the little bracelets with things like LIVE STRONG or FIGHT FOR A CURE or whatever written across them. It seems like there’s one of those for everything nowadays, and quite frankly it’s gotten a bit out of control.

The other thing that is out of hand is people begging for things “for the children.” Please, support this random cause–it’s for the children! Please cease to exercise your rights, as it may scar or offend the children! People are asking you to alter your lifestyle as a surrogate for their own shoddy parenting skills, and it gets old fast to hear people make an inane argument for something stupid and then follow it with a visceral appeal “for the children” rather than using logic or supporting facts to make a case.

And so it is with great delight that I saw MonkeyGirl’s new coffee mug. It reads,

POOP STRONG

FOR THE CHILDREN

It turns out that there is quite a variety of poop strong products out there. There are pens, shirts, bracelets, and many others. I may just have to invest in a handsome set of those poop strong pens; I could even hang the bracelet from my stethoscope, as some of the more “hip” people at the hospital have been doing lately.

Good: Patient meets parameters for extubation. Termination of mechanical ventilation and removal of the ET tube commences.

Bad: Patient immediately develops audible stridor. Accessory muscle use noted.

Worse: Administration of two back-to-back racemic epinephrine nebs does not improve the stridor. Patient begins paradoxical respiration at a rate of almost forty. Stridor worsens. Physician is called but is stuck in elevator. Emergency Backup Physician is called.

Even Worse: During the physicians first attempt at intubation, the patient coughs violently and sends yellow-blood-tinged sputum flying across the room, spreading infectious disease and generally being nasty.

Even More Worse: During physicians second attempt at intubation, the patient wretches and a funnel of gore gurgles up from within his innards and percolates in his mouth before being sucked down by the patients rapid inspiration. Suction recovers some but certainly not all of the gore.

Worser than all that: Once the airway is in place and confirmed with lung sounds and CO2, the ventilator is connected. The ventilator tubing fills with vomit and needs to be changed immediately. The gore was evidently much worse than anticipated. It is chunky. RT tries heroically to avoid adding their own vomit to this already impressive collection of emesis.

The worsest: Before all this, the respiratory therapist told the family that “99 times out of 100, this goes smoothly.” Evidently nature abhors the implied promise of smoothness in medicine.

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You’d think I’d have learned that by now, but apparently I’m a lordly work of irony.

There are a lot of patients who suffer from problems that are difficult to label in an appropriate manner. As part of our shift report at the hospital, I am expected to give a diagnosis with each patient that I am reporting off on.  Since I am not a physician and I do not have the power to diagnose somebody, I rely on the dictated history and physical in the patients record to get my information.

Oftentimes when reading the H&P of intensive care patients you are presented with a laundry list of problems. A typical patient could present with type II diabetes, early Alzheimers dementia,  coronary artery disease, COPD, acute renal failure, and obesity. But even a lengthy list like this might not be enough to fully describe the condition of the patient. To really give the full essence of the patient, to accurately convey the experience of caring for them, sometimes you need a little bit more than the regular bland diagnoses.

That is why I am glad that The Happy Hospitalist has jotted down a wonderful list of diagnoses that accurately describe many of our patients in a nutshell. I quote from the top of the list:

ISOBO-  Inappropriate Secretion of  Offensive Bodily Odor

Failure to Parent

Abdominal pain of absolutely no significance

Vitamin IQ deficiency

Good post over at G’s Spot. You might be an RT if…

The COW implementation at work has arrived. It has been an interesting couple of days, but I am too tired to write more at this time, so it’ll have to wait. So I leave you with two things: first, the promise of an excellent music video that relates to the ICU will be here tomorrow. Stay tuned for that…and for my signoff tonight, I leave you with a thought:

An excellent name for a new brand of Whiskey would be “Gilgamash.” You could even write a book about the distillation of said whiskey entitled “The Epic of Gilgamash.”  This is only funny to me because I have not had nearly enough sleep and I have been working waaaay too much overtime.

Funny video tomorrow, COW philosophy later.

A nurse and I were talking about a patient today. The patient is a young woman who was recently paralyzed. She has only just begun to understand that it’s not “paralyzed for now,” it’s “paralyzed for the rest of your life.” The horror and the enormity of being permanently paralyzed from the neck down has sunk in. She is quite understandably devastated.

“In fact,” I said to the nurse with whom I was conversing, “just the other day we were talking and she asked me to pull the plug and let her die. It was really sad. I really think she wishes she had died in the accident. She kept mouthing ‘pull the plug, pull the plug’ until I left.”

“Awww…that’s terrible. But doesn’t she have that right? I mean, if she’s competent and she can voice her wishes, don’t we have to honor them?”

“I think she does, absolutely. If she’s competent and she can tell us to stop*, I don’t know why we should keep going. I don’t know if I would want to live like that.”

There was a slight pause as the nurse and I pondered. What would it be like to have such a fate, conscious and aware but completely immobile forever? How do you deal with that, with the horror of never being able to do anything for yourself?

I was brought back to the moment as the nurse took a deep breath and spoke.

“I guess she’d probably have a hard time signing the consent to withdraw form, wouldn’t she?”

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I thought it was funny. But then I may be crazy.

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*Of course, it can be argued that anybody who is expressing suicidal ideation is incompetent by definition. This is a tricky argument and one I won’t get into for now.

A scene from the ICU today:

“Hey, what happened? I thought that the kid in 8 was supposed to go to a long-term place.”

“He was going to but then they found out that his brain is growing mold. I guess some Aspergillous got in underneath the plate in his skull and now he’s full of some kind of fungus. Infectious Disease doesn’t know what to do because nothing will cross the blood-brain barrier. I guess we could spray fungicide on the plate…can you imagine growing fungus in your brains?”

“Well, look on the bright side. He used to just be a vegetable but with the extra mushrooms he’s got the entire produce section down.”